Sample Hand Hygiene Observation Record

To ensure its physicians and staff members in its ambulatory surgery centers follow proper hand hygiene guidelines, the Laser Spine Institute developed a hand hygiene observation record to track adherence to the hand rubbing and hand washing rules.


The form is for recording employee-type and then noting whether hands were rubbed/washed before patient contact and after contact with patient, equipment, environment, or removing gloves, and if gloves were worn when required.


The form is then used to determine percent adherence with hand rubbing/washing and glove-wearing.


To download a copy of this form you can adapt for use in your ASC, click here (pdf).


Source: Laser Spine Institute


Read about more valuable infection control and quality tools:


- Patient Safety Tool: Guidelines and Procedures for Surgical Site Infections


- Sample Sterile Processing Department Testing and Load Form and QI Worksheet


- Sample Surgery Center Hand Washing Flier for Patients

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